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Pdf 123 PMID: 24620729 [Cited 2016 Nov 11] Research Implementation research on community health workers’ provision of maternal and child health services in rural Liberia Peter W Luckow,a Avi Kenny,b Emily White,b Madeleine Ballard,c Lorenzo Dorr,b Kirby Erlandson,d Benjamin Grant,b Alice Johnson,b Breanna Lorenzen,e Subarna Mukherjee,b E John Ly,b Abigail McDaniel,b Netus Nowine,f Vidiya Sathananthan,b Gerald A Sechler,g John D Kraemer,h Mark J Siedneri & Rajesh Panjabig Objective To assess changes in the use of essential maternal and child health services in Konobo, Liberia, after implementation of an enhanced community health worker (CHW) programme. Methods The Liberian Ministry of Health partnered with Last Mile Health, a nongovernmental organization, to implement a pilot CHW programme with enhanced recruitment, training, supervision and compensation. To assess changes in maternal and child health-care use, we conducted repeated cross-sectional cluster surveys before (2012) and after (2015) programme implementation. Findings Between 2012 and 2015, 54 CHWs, seven peer supervisors and three clinical supervisors were trained to serve a population of 12 127 people in 44 communities. The regression-adjusted percentage of children receiving care from formal care providers increased by 60.1 (95% confidence interval, CI: 51.6 to 68.7) percentage points for diarrhoea, by 30.6 (95% CI: 20.5 to 40.7) for fever and by 51.2 (95% CI: 37.9 to 64.5) for acute respiratory infection. Facility-based delivery increased by 28.2 points (95% CI: 20.3 to 36.1). Facility-based delivery and formal sector care for acute respiratory infection and diarrhoea increased more in agricultural than gold-mining communities. Receipt of one-or-more antenatal care sessions at a health facility and postnatal care within 24 hours of delivery did not change significantly. Conclusion We identified significant increases in uptake of child and maternal health-care services from formal providers during the pilot CHW programme in remote rural Liberia. Clinic-based services, such as postnatal care, and services in specific settings, such as mining areas, require additional interventions to achieve optimal outcomes. Introduction respiratory infection and malaria; and (ii) maternal and new- born care. Here, we describe the programmatic components, Over 95% of global maternal and child deaths occur in 75 low- implementation and an assessment of changes in maternal and and middle-income countries and remote populations within child health-care use three years after implementation. these countries often bear the greatest burden.1,2 Many countries are exploring strategies to scale up community health worker (CHW)-based programmes, which have been demonstrated to Methods improve health in the domains of maternal and child health, Setting and participants access to family planning and prevention of human immuno- deficiency virus (HIV) infection, malaria and tuberculosis.3,4 The programme took place in Konobo district in south-eastern In Liberia, an estimated 60% (1.2 million people) of the ru- Liberia. Konobo is one of Liberia’s most remote regions, com- ral population lives more than 5 km from the nearest health fa- prised of 2983 km2 of rainforest, with a population density of cility and the country has among the highest maternal and child 4.1 people/km2. In 2012, approximately 12 000 residents in mortality rates globally, 725 deaths per 100 000 live births and the district lived more than 5 km from the nearest clinic. One 70 deaths per 1000 live births, respectively.5–7 In 2012, the health quarter were women of reproductive age (15–49 years) and 16% ministry partnered with Last Mile Health, a nongovernmental were children under five years. These two demographic groups organization, to pilot a programme for enhanced CHW-based represented the target population of the programme. All 44 re- health care for remote populations (those living farther than mote communities in Konobo, located more than 5 km from the 5 km or a one hour walk from the nearest health facility). The district’s only health clinic were involved with the programme. programme aimed to increase coverage of essential maternal The average road distance from these communities to the clinic and child health services through enhanced recruitment, train- was approximately 25 km and the mean population of the ing, supervision and compensation of CHWs. Responsibilities communities was 276 people. According to the 2012 Liberian of CHWs included provision of: (i) integrated community case Demographic and Health Survey, Konobo had worse maternal management of childhood illnesses, including diarrhoea, acute and child health outcomes than other rural Liberian districts.8 a Geisel School of Medicine at Dartmouth College, Hanover, United States of America (USA). b Last Mile Health, Monrovia, Liberia. c Department of Social Policy and Intervention, University of Oxford, Oxford, England. d Harvard Medical School, Boston, USA. e University of Minnesota Medical School, Minneapolis, USA. f Grand Gedeh County Health Team, Ministry of Health, Monrovia, Liberia. g Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA. h Department of Health Systems Administration, Georgetown School of Nursing and Health Studies, Washington, USA. i Department of Medicine, Harvard Medical School, Boston, USA. Correspondence to Rajesh Panjabi (email: [email protected]). (Submitted: 31 May 2016 – Revised version received: 7 October 2016 – Accepted: 9 October 2016 ) Bull World Health Organ 2017;95:113–120 | doi: http://dx.doi.org/10.2471/BLT.16.175513 113 Research Maternal and child care in Liberia Peter W Luckow et al. Implementation to health clinics. A typical training took therapy. Malaria was diagnosed with two weeks to complete. Physician assis- rapid diagnostic tests in children, with a We implemented the programme be- tants and registered nurses led the training measured fever. Additionally, CHWs con- tween 2012 and 2015 in a stepwise fash- sessions that focused on clinical skills, ducted home-based antenatal care educa- ion over three geographic areas within such as history-taking, physical examina- tion, helped design birth plans, scheduled Konobo district. Integrated community tion and specific clinical procedures, such facility-based deliveries, screened preg- case management of childhood illness as rapid diagnostic testing for malaria. nant women and neonates for danger was launched in February 2013, August After the start of the Ebola virus disease signs, referred cases with danger signs 2013 and March 2014. Maternal and outbreak, we added a training module on to the clinic and promoted exclusive newborn care services were launched surveillance for Ebola symptoms. breastfeeding. CHWs provided services in November 2012, December 2013 and CHWs received weekly supervision at no cost to community members. To April 2015. visits from peer supervisors who were further promote health-care utilization, CHW recruitment and staffing trained in project and supply manage- CHWs organized community health ment, supportive supervision and refer- committees that partnered with trained We recruited CHWs through commu- rals. Supervision visits were designed to traditional midwives to refer expectant nity nomination, as recommended by last one hour each and consisted of form mothers to stay at maternal waiting homes the 2008 National policy and strategy on reviews, patient audits and restocking of (a residence near the clinic for at-term community health services.9 Our recruit- essential commodities. High-performing mothers), until childbirth. Beginning ment process added several components, CHWs were promoted to peer supervi- in April 2013, the programme paid the including (i) completion of a literacy sors, and were equipped with a motorbike midwives US$ 3–5 for clinic referrals, and test; (ii) an in-person interview to assess for travel during supervision visits. Ini- mothers who delivered in the clinic were motivation and communication skills; tially, the visits were unstructured and left provided transport reimbursements and and (iii) training and subsequent skills’ to the discretion of individual supervisors, food stipends. assessment for candidates that passed the however, since May 2013, supervision We modified several elements of the interview. After this additional three-step visits included the use of quality assur- programme during the Ebola virus disease screening and assessment, we identified ance checklists and randomly-sampled outbreak. After the start of the outbreak and hired the highest scoring CHWs. We patient audits led by the peer supervisors. in 2015, CHWs performed active surveil- also conducted a follow-up competency Separately, clinical supervisors conducted lance through monthly household visits. assessment during the first 90-days of monthly field supervision visits to assess While there were no confirmed cases their employment. We recruited CHWs adherence to clinical protocols and pro- of Ebola in the study area, use of rapid from the communities in which they vide formative feedback based on form malaria diagnostic tests was suspended resided, and they served communities reviews and direct observation of patient to ensure the safety of CHWs, and the within a 30-minute walk from their home interactions. programme adopted treatment protocols community. Although the 2008 National policy based on self-reported signs and symp- We also interviewed and hired two and strategy on community health
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